2016_1107 IRRIGATION DOMESTIC FIRELINE�.
The following form must be completed for each assembly tested A signed and dated original
must be submitted to the public water supplier for recordkeeping purposes:
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL PWS I.D. #0570040
(Customer) .
MAILING ADDRESS: '�-5�
CONTACT PERSON/PHONE•�,�,� .�.�y Qt30 c�t $
LOCATION OF SERVICE:����,�oe..�elc-y+�p
The backflow prevention assembly detailed below has been tested and maintained as required by
commission regulations and is certified to be operating within acceptable parameters.
TY�E OF ASSEMBLY
❑Reduced Pressure Principle ❑Reduced Pressure Principle-Detector
�DoubleCheckValve ❑Double Check-Detector
❑PressureVacuumBreaker ❑Spill-Resista.nt Pressure Vacuum Breaker
Manufacturer A„��� Model Number���$ _ Size l�
Located At Serial Number )���'�
Is the assembly installe in accordance with manufacturer recommendations andlor local codes?
Reduced Pressure Princi le Assembl Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Valve Air Inlet Check Valve
1 st Check 2nd Check
Held at J=Z� psi Held at 3•� psid Opened at Opened at Held at
Initial Test Closed Tigh ' Closed Tight � psid psid psid
Leaked❑ LeakedL! Did not open ❑ Did not open ❑ Leaked❑
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight❑ Closed Tight❑ psid psid psid
Test gauge used:Make/Model�r,�.��b-2�b-�:J��. SN:�{t�12�6(c�
Date Tested for Accuracy: S��'!t G,
Remarks:
The above is certified to be true at the time of testing.
Firm Name���o,,..�,,,.��� F'i�� �e}u�-�Firm A ddress i�� . '��.Wo`� 1..�-r T3( �b`$
Certified Tester(print)'�1�...��,�� Certified Tester(signature)
Firm Phone#2.!'�.�14N,31R�-1 Cert.Tester No.3Pt�3�lZ-9yS Date (T f I lo
*TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
**USE ONLY MANUFACTURER'S REPLACEMENT PARTS
White-City Copy Yellow-Customer Copy Pink-Tester's Copy